Effect of Knowledge of Patients' HIV Positive Status on the Attitude of Health Workers in Zambia

Background: Zambia, Southern Africa, has one of the world's most devastating HIV and AIDS epidemics. More than one in every seven adults in the country is living with HIV1 and this disease is the leading cause for patient work load in all health institutions putting a strain on the depleted work force. Fear of contracting HIV from such patients is real and likely to impact negatively on the attitude of patients if they knew the HIV status of the patient to be positive. This study was undertaken to investigate the influence of knowing the HIV status of a patient to be positive on the various decisions of healthcare providers regarding provision of health care to such patients.Study design: This was a cross-sectional study conducted between 2001 and 2005 in Zambia among health workers during the costing of basic health care package among selected health centres.Outcome Measures: Information was obtained by questionnaire and scored on Likerts' scale regarding whether a patient with known HIV positive test result should be: nursed in isolation ward, staff and health professionals should be notified , beds of such patients should be specially marked, relatives should be informed (with and without consent), relatives to be the ones to nurse such a patient, the terminally ill one should be denied resuscitation, staff would refuse to handle a patient, they would encourage a patient to use herbs and prayers rather than HAART, medical treatment was ever refused, admission was ever refused and surgeon ever refused operating on patient with positive HIVtest.Results: Atotal 180 health workers comprising 120 (66.7%) nurses, 25(13.9%) physicians, 22 (12.2%) laboratory technicians and 13 (7.2%) environmental health technicians were studied. Most of interviewees felt that such patients should not be discriminated against. Over 80% felt that health staff should be availed this sero-status while 50% felt that relatives should be informed of the status even without consent and that the relatives nurse these patients .Half thought that resuscitation should not be done for terminally ill such patients and a third said they will offer prayers instead of HAART while half said they will recommend herbs. A third of physician reported having refused to operate on such patient. Conclusion: While most health-care professionals surveyed reported being in compliance with their ethical obligations the findings are a sources of concern. It would be useful to repeat this study now that HAART and post-exposure prophylaxis have been rolled out in Zambia. Keywords: Attitude, Health workers, Patient’s HIV statu

Association Between Unplanned Pregnancy and HIV Seropositivity Disclosure to Marital/Cohabitating Partner Among Post-natal Women in Lusaka, Zambia

Background: Disclosure of a positive HIV result to partner is an important step towards prevention of infection, early diagnosis and optimum care especially in the context of PMTCT. Little is known about the disclosure patterns of postnatal women in relation to planning status of index pregnancy. This study explored this aspect.Objectives: To determine any association between unplanned pregnancy and HIV seropositivity disclosure to stable partner among postnatal women in Lusaka.Design: Using a cross-sectional study design the disclosure patterns of 100 postnatal women with unplanned pregnancies were compared to a similar group of 100 women with planned pregnancies.Results: The crude OR for disclosure of a positive HIV result to partner (planned pregnancy/unplanned pregnancy) was 1.839 (CI= 1.002-3.372). After adjusting for participant and partner's feelings after pregnancy discovery, partner's occupation, condom use in the relationship and length of stay with partner this OR was 2.835 (CI=0.690 -11.643). 66.7% of those that reported that their partners had worries, depression or sadness after disclosure had unplanned pregnancies whereas 83.3% of those that expressed no emotions had planned pregnancies.Conclusions: Possibility of antenatal HIV seropositivity disclosure to partner is the same whether the pregnancy is planned or not. Unplanned pregnancy is associated with more negative reactions by partner after disclosure

Emergency Contraception Among Women With Abortion At University Teaching Hospital In Lusaka, Zambia

Background: The maternal mortality ratio for Zambia is 591/100 000 live births. Globally between 15 – 30% of the maternal deaths are due to unsafe abortions. According to the Zambian demographic health survey (ZDHS), the contraceptive prevalence rate was 34% (CSO, 2003). The unmet need for family planning was 27%. Emergency contraception pill (ECP) was officially launched in Zambia in 1998 by the Ministry of Health with the aim of strengthening reproductive health. It can be obtained free of charge at public health institutions and also as an over the counter drug.Objective: To determine knowledge, Practice and attitude towards Emergency Contraception (EC) among women with abortion at the University Teaching Hospital (UTH), Lusaka, Zambia.Design: A cross-sectional descriptive study design and an interview schedule were administered to 200 women admitted to UTH with abortion aged between 18 – 49 years old.Main outcome measure: Emergency contraception awareness among women with abortions at UTH, Lusaka.Results: The median age of the participants was 19 years. Only 7.5% had ever heard of emergency contraceptive pills (ECPs). Majority (70%) were married with the majority reporting being married for less than 5 years. The contraceptive ever use rate was 78.5%and 58% the participants had their first pregnancies as teenagers. Almost a third (31%) was nulliparous. The most common sources of information about EC were friends (80%). Level of education was significantly associated with the outcome of EC awareness (OR = 9.5; 95% CI [3.06 – 29.87] (P value 0.001). Another factor that was significantly associated with the outcome of EC awareness was the level of EC knowledge (OR = 0.00; 95% CI [0.00 – 0.02](P value 0.001). Other factors such as age, place of residence and marital status were not significantly associated with EC awareness.Conclusion: Knowledge about Emergency Contraception (EC) among women with abortions admitted to UTH is low. Friends are an important source of EC information. Awareness and knowledge of EC should be increased

The Determinants and Outcomes of Second Trimester Abortion at the University Teaching Hospital

Background: Mid trimester abortion constitutes 10-15% of all induced abortions worldwide and accounts for the majority of complications. In Africa, studies demonstrating the proportion of second trimester abortions are few.  However to appropriately intervene with a view to reducing the morbidity and mortality due to mid trimester   abortions, the determinants in our setting must be established as well as the outcomes of uterine evacuation in  this trimester. The aim of this study was to explore the determinants and outcomes of second trimester abortions at UTH.Design: Cross sectional non interventional descriptive study.Setting: University Teaching Hospital, a tertiary referral hospital in Lusaka, ZambiaPopulation: Pregnant women requiring second trimester abortion care.Methods: A total of 145 second trimester cases were seen, involving women aged 13-46 years of age eitherrequesting termination of pregnancy or presenting with spontaneous or induced abortion. The enrolled studyparticipants all underwent a standard clinical assessment during which their respective clinical findings wererecorded on data sheets. Data analysis was done using SPSS version 17.Results: The point prevalence of second trimester abortion was 15.3%. The mean frequency of abortion per patient was 1. The index abortion was for a first pregnancy in 84% of the women. Out of 145 women who were  admitted 119 (82.1%) were linked to spontaneous abortions, 16(11%) with medically/surgically induced abortion  and 10(6.9%) with self-induced abortions. More women, 128(88%) were not using some form of contraception to  avoid pregnancy. Few, 17(12%) actually used some form of contraception prior to index pregnancy. Five (3.4%)  out of 26 who had induced abortion had desired pregnancy. Of the delay factors, the most frequent was conflict  with partner. Amongst those who had spontaneous abortion, illness was reported as most frequent determinant  (49.7%). It was observed that there was no statistically significant association between seeking care and with any  delay factors. With regard to standard of care or health system factors, overall 89% were provided with  ppropriate uterine evacuation method while the rest were not. Fifty percent did not receive analgesia. The mean time   between expulsion of fetus and uterine evacuation was 4.31 hours. Complications noted included uterine  perforation, hemorrhage, cervical or vaginal lacerations, shock and even death.Conclusion: The determinants of the second trimester abortion cases at the University Teaching Hospital are social, economic, health system factors, trauma, illness and unknown factors. The outcomes of second trimester  abortion in terms of complications are varied. These are due to patient factors and methods used for uterine  evacuation. The outcomes included uncomplicated complete abortion, retained products of conception,   haemorrhage, uterine perforation, pain, shock, infection, lacerations, delayed vaginal bleeding and death. The  methods of uterine evacuation varied from patient to patient but the overall outcome of the patient was not   significantly affected by this.Key Words: Second trimester,Abortion, determinants and outcomes

HIV/AIDS and Postnatal Depression at the University Teaching Hospital, Lusaka, Zambia

Objective: To study the contribution of HIV/AIDS to the problem of postnatal depression among women receiving postnatal care at University Teaching Hospital (UTH), Lusaka, Zambia.Background: Postnatal depression (PND), a major depressive episode during the puerperium, affects between 10% and 22% of adult women before the infant's first birthday. HIV seropositivity has been associated with increased risk of mental disease, but its influence on postnatal depression has not been fully explored.Methods: This was a cross-sectional study, involving 229 mothers receiving postnatal care at UTH. The presence of postnatal depression and mean scores on the Edinburgh Postnatal Depression Scale (EPDS) were assessed, along with the patients' HIV status and other demographic and clinical characteristics.Results: 146 of 229 patients (64%) had depressive symptoms as measured by an EPDS score ≥8. Sixtyfour women (28%) had severe PND, defined as an EPDS score ≥13. There were 46 HIV positive women (20.1%). HIV status was not associated with PND (adjusted OR 1.22, 95% CI 0.50-2.96) or severe PND (adjusted OR 1.77, 95% CI 0.68-4.61). Mixed mode of infant feeding and parity of 4-5 were independently associated with PND.Conclusions: Depression is a real health problem among mothers attending postnatal care at UTH. HIV status was not independently associated with increased risk of postnatal depression.Keywords: postnatal depression, puerperium, Edinburgh Postnatal Depression Scale, prevalence of HIV/AID

Incidence of abortion-related near-miss complications in Zambia: cross-sectional study in Central, Copperbelt and Lusaka Provinces

OBJECTIVES: To describe the magnitude and severity of abortion-related complications in health facilities and calculate the incidence of abortion-related near-miss complications at the population level in three provinces in Zambia, a country where abortion is legal but stigmatized. STUDY DESIGN: We conducted a cross-sectional study in 35 district, provincial and tertiary hospitals over 5 months. All women hospitalized for abortion-related complications were eligible for inclusion. Cases of abortion-related near-miss, moderate and low morbidity were identified using adapted World Health Organization (WHO) near-miss and the prospective morbidity methodology criteria. Incidence was calculated by annualizing the number of near-misses and dividing by the population of women of reproductive age. We calculated the abortion-related near-miss rate, abortion-related near-miss ratio and the hospital mortality index. RESULTS: Participating hospitals recorded 26,723 births during the study. Of admissions for post-abortion care, 2406 (42%) were eligible for inclusion. Near-misses constituted 16% of admitted complications and there were 14 abortion-related maternal deaths. The hospital mortality index was 3%; the abortion-related near-miss rate for the three provinces was 72 per 100,000 women, and the near-miss ratio was 450 per 100,000 live births. CONCLUSIONS: Abortion-related near-miss and mortality are challenges for the Zambian health system. Adapted to reflect health systems capabilities, the WHO near-miss criteria can be applied to routine hospital records to obtain useful data in low-income settings. Reducing avoidable maternal mortality and morbidity due to abortion requires efforts to de-stigmatize access to abortion provision, and expanded access to modern contraception. IMPLICATIONS: The abortion-related near-miss rate is high in Zambia compared with other restrictive contexts. Our results suggest that near-miss is a promising indicator of unsafe abortion; can be measured using routine hospital data, conveniently defined using the WHO criteria; and can be incorporated into the frequently utilized prospective morbidity methodology

Preconception ART and preterm birth: real effect or selection bias?

In a recent systematic review and meta-analysis, Uthman and colleagues 1 examined the relation between timing of antiretroviral therapy (ART) initiation and adverse pregnancy outcomes. The researchers noted that women continuing preconception ART had a modestly higher risk of preterm birth (ie, birth before 37 weeks) compared with those initiating ART in pregnancy (RR 1·20, 95% CI 1·01–1·44)

National policies and care provision in pregnancy and childbirth for twins in Eastern and Southern Africa: A mixed-methods multi-country study

Background: High-risk pregnancies, such as twin pregnancies, deserve particular attention as mortality is very high in this group. With a view to inform policy and national guidelines development for the Sustainable Development Goals, we reviewed national training materials, guidelines, and policies underpinning the provision of care in relation to twin pregnancies and assessed care provided to twins in 8 Eastern and Southern African countries: Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. Methods and findings: We located policies and guidelines by reviewing national repositories and by contacting experts to systematically map country-level maternal and newborn training materials, guidelines, and policies. We extracted recommendations for care for twins spanning ante-, intra-, and postpartum care that typically should be offered during twin pregnancies and childbirth. We compared care provided for mothers of twins to that provided for mothers of singletons during the ante-, intra-, and postpartum period and computed neonatal mortality rates using the most recent Demographic and Health Surveys (DHS) data for each country. There was a paucity of guidance on care specifically for twin or multiple pregnancies: None of the countries provided clear guidance on additional number of antenatal care visits or specific antenatal content, while 7 of the 8 countries recommended twins to be delivered in a comprehensive emergency obstetric and neonatal care facility. These results were mirrored by DHS results of 73,462 live births (of which 1,360 were twin) indicating that twin pregnancies did not receive more frequent or intensified antenatal care. The percentage of twin deliveries in hospitals varied from 25.3% in Mozambique to 63.0% in Kenya, and women with twin deliveries were between 5 and 27 percentage points more likely to deliver in hospitals compared to women with singleton live births; this difference was significant in 5 of the 8 countries (t test p \u3c 0.05). The percentage of twin deliveries by cesarean section varied from 9% in Mozambique to 36% in Rwanda. The newborn mortality rate among twins, adjusted for maternal age and parity, was 4.6 to 7.2 times higher for twins compared to singletons in all 8 countries. Conclusions: Despite the limited sample size and the limited number of clinically relevant services evaluated, our study provided evidence that mothers of twins receive insufficient care and that mortality in twin newborns is very high in Eastern and Southern Africa. Most countries have insufficient guidelines for the care of twins. While our data do not allow us to make a causal link between insufficient guidelines and insufficient care, they call for an assessment and reconceptualisation of policies to reduce the unacceptably high mortality in twins in Eastern and Southern Africa

Planned early delivery for late preterm pre-eclampsia in a low- and middle-income setting: a feasibility study.

BACKGROUND: Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity globally. Planned delivery between 34+0 and 36+6 weeks may reduce adverse pregnancy outcomes but is yet to be evaluated in a low and middle-income setting. Prior to designing a randomised controlled trial to evaluate this in India and Zambia, we carried out a 6-month feasibility study in order to better understand the proposed trial environment and guide development of our intervention. METHODS: We used mixed methods to understand the disease burden and current management of pre-eclampsia at our proposed trial sites and explore the acceptability of the intervention. We undertook a case notes review of women with pre-eclampsia who delivered at the proposed trial sites over a 3-month period, alongside facilitating focus group discussions with women and partners and conducting semi-structured interviews with healthcare providers. Descriptive statistics were used to analyse audit data. A thematic framework analysis was used for qualitative data. RESULTS: Case notes data (n = 326) showed that in our settings, 19.5% (n = 44) of women with pre-eclampsia delivering beyond 34 weeks experienced an adverse outcome. In women delivering between 34+0 and 36+6 weeks, there were similar numbers of antenatal stillbirths [n = 3 (3.3%)] and neonatal deaths [n = 3 (3.4%)]; median infant birthweight was 2.2 kg and 1.9 kg in Zambia and India respectively. Lived experience of women and healthcare providers was an important facilitator to the proposed intervention, highlighting the serious consequences of pre-eclampsia. A preference for spontaneous labour and limited neonatal resources were identified as potential barriers. CONCLUSIONS: This study demonstrated a clear need to evaluate the intervention and highlighted several challenges relating to trial context that enabled us to adapt our protocol and design an acceptable intervention. Our study demonstrates the importance of assessing feasibility when developing complex interventions, particularly in a low-resource setting. Additionally, it provides a unique insight into the management of pre-eclampsia at our trial settings and an understanding of the knowledge, attitudes and beliefs underpinning the acceptability of planned early delivery